Provider Demographics
NPI:1902234214
Name:FAIDLEY, JESSICA D
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:D
Last Name:FAIDLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11110 MEDICAL CAMPUS ROAD
Mailing Address - Street 2:SUITE 151
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742
Mailing Address - Country:US
Mailing Address - Phone:301-797-7600
Mailing Address - Fax:301-797-1249
Practice Address - Street 1:11110 MEDICAL CAMPUS RD
Practice Address - Street 2:SUITE 151
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6700
Practice Address - Country:US
Practice Address - Phone:301-797-7600
Practice Address - Fax:301-797-1249
Is Sole Proprietor?:No
Enumeration Date:2013-10-23
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0005202363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical